ABT-DSI08 Congrats Packet - Dance - Wayne State University

PHYSICAL EXAMINATIONPlease answer each item carefully and accurately to assure a medically meaningful document. The information is strictlyconfidential. In order to participate in the program, the ABT – Detroit Summer Intensive requires you to have a completeexamination.Name (Last) First MI Soc. Sec. # U.S. Citizen Birth date SexFemale MalePermanent Address City State Zip PhonePerson to NotifyRelationshipPhoneIn EmergencyAddress of Above City State Zip Personal Physician PhoneWill you be covered by a medical Yes Noinsurance policy while enrolled?If yes, name of insurance companyIMMUNIZATIONS: The ABT Summer Intensive requires that all students born after 1956 must have had 2 doses of a measles containing vaccine (rubella,M.R., M.M.R.) prior to registration. One dose must have been after 1980 and at least one of the doses must have been a M.M.R.Required First Immunization Second ImmunizationVaccine/Type Month Date Year Vaccine/Type Month Date YearMeaslesGerman MeaslesMumpsOr in lieu of the above: Positive titer date (Rubella) ____/____/____Positive titer date (Rubella) ____/____/____RecommendedPolio ____/____/____Please specify dates*Tetanus ____/____/____*A tetanus booster or basic series within the past 6 years is recommended for admissionHepatitis B (3 shots) ____/____/____ ____/____/____ ____/____/____1 st 2 nd 3 rdTB Skin Test (PPD) ____/____/____Results: Positive ______mm / Negative _______________________________________________ ___________________ _____________________________________Physician or Authorized Signature Date License # or Office StampFatherMotherSisterSisterBrotherBrotherFamily HistoryAge Occupation Significant Medical Problems26Physical Exam Page 1 4/22/2008